Posterior prolapse (rectocele)

A posterior prolapse occurs when the thin wall of fibrous tissue (fascia) that separates the rectum from the vagina weakens, allowing the vaginal wall to bulge. Posterior prolapse is also called a rectocele (REK-toe-seel) because typically, though not always, it's the front wall of the rectum that bulges into the vagina.

Childbirth and other processes that put pressure on the fascia can lead to posterior prolapse. A small prolapse may cause no signs or symptoms. If a posterior prolapse is large, it may create a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, it's rarely painful.

If needed, self-care measures and other nonsurgical options are often effective. In severe cases, you may need surgical repair.

Upright posture

Walking upright places weight on a woman's pelvic floor and is the main reason women experience posterior prolapse.

Increased pelvic floor pressure

Other conditions and activities that increase the pressure already on the pelvic floor and can cause or contribute to posterior prolapse include:

Chronic constipation or straining with bowel movements

Chronic cough or bronchitis

Repeated heavy lifting

Being overweight or obese

Pregnancy and childbirth

Pregnancy and childbirth increase the risk of posterior prolapse. This is because the muscles, ligaments and fascia that hold and support your vagina become stretched and weakened during pregnancy, labor and delivery. As a result, the more pregnancies you have, the greater your chance of developing posterior prolapse.

Not everyone who has had a baby develops posterior prolapse. Some women have very strong supporting muscles, ligaments and fascia in the pelvis and never have a problem. Women who have only had cesarean deliveries are less likely to develop posterior prolapse. But even if you haven't had children, you can develop posterior prolapse.

The following factors may increase your risk of experiencing posterior prolapse:

Genetics. Some women are born with weaker connective tissues in the pelvic area, making them naturally more likely to develop posterior prolapse. Others are born with stronger connective tissues.

Childbirth. If you have vaginally delivered multiple children, you have a higher risk of developing posterior prolapse. If you've had tears in the tissue between the vaginal opening and anus (perineal tears) and incisions that extend the opening of the vagina (episiotomies) during childbirth, you may also be at higher risk.

Aging. Your risk of posterior prolapse increases as you age because you naturally lose muscle mass, elasticity and nerve function as you grow older, causing muscles to stretch or weaken.

Obesity. A high body mass index is linked to an increased risk of posterior prolapse. This is likely due to the chronic stress that excess body weight places on pelvic floor tissues.

In most cases, your doctor diagnoses posterior prolapse during a pelvic examination of your vagina and rectum.

Possible tests for rectocele include:

Pelvic exam. During the exam, your doctor may ask you to bear down as if having a bowel movement. This may cause the posterior prolapse to bulge, so your doctor can assess its size and location. To check the strength of your pelvic muscles, you may also be instructed to tighten (contract) them, as if you're stopping the stream of urine. Your doctor may examine you while lying down and while standing up.

Questionnaire. You may fill out a form that helps your doctor assess how far the bulge extends into your vagina and how much it affects your quality of life. Information gathered also helps guide treatment decisions.

Imaging tests. Imaging tests usually aren't needed to diagnose posterior prolapse. Rarely, your doctor may identify something during the physical exam that needs further evaluation. In that case, you may have an imaging test, such as magnetic resonance imaging (MRI) or an X-ray exam, to determine the size of the tissue bulge and how efficiently your rectum empties (defecography).

Treatment approaches depend on the severity of the posterior prolapse. Options include:

Observation. If your posterior prolapse causes few or no obvious symptoms, you may not need treatment. Simple self-care measures, such as performing exercises called Kegels to strengthen your pelvic muscles, may provide symptom relief.

Pessary. A vaginal pessary is a plastic or rubber ring inserted into your vagina to support the bulging tissues. Several types of pessaries are available, including some you can remove to clean, and others your doctor must remove periodically to clean.

Surgery. If the posterior prolapse protrudes outside your vagina and is especially bothersome, you may opt for surgery. Surgery to repair posterior prolapse will repair the tissue bulge, but it won't fix impaired bowel function.

Your doctor will likely suggest surgery if you have prolapse of other pelvic organs in addition to posterior prolapse. Surgical repair for each condition can be completed at the same time.

Using a vaginal approach, surgery usually consists of removing excess, stretched tissue that forms the posterior prolapse. Occasionally, the surgical repair may involve using a mesh patch to support and strengthen the wall between the rectum and vagina.

If you're thinking about becoming pregnant, your doctor may recommend that you delay surgery until after you're done having children. Using a pessary may help relieve your symptoms in the meantime.

Hold the contraction for five seconds, then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds.)

Work up to holding the contractions for 10 seconds at a time.

Aim for at least three sets of 10 repetitions each day.

Ask your health care provider for feedback on whether you're using the right muscles. Kegel exercises may be most successful when they're taught by a physical therapist and reinforced with biofeedback. Biofeedback involves using monitoring devices that help ensure you're tightening the proper muscles, with optimal intensity and length of time.

Once you've learned the proper method, you can do Kegel exercises discreetly just about anytime, whether you're sitting at your desk or relaxing on the couch.